It was a massive but. Sandi was a fashion magazine editor who often worked long days and felt a near-constant stress to look fabulous. But early menopause had sabotaged that confidence, leaving her feeling frustrated and confused. It wasn’t just miserable physical symptoms like sleeplessness, brain fog, mood swings, an "arctic level" (as she called it) sex drive, and dreaded hot flashes that she suddenly experienced out of nowhere—Sandi was also going on an emotional and spiritual journey that many women don’t anticipate or experience until later in life.

Early menopause or primary ovarian insufficiency (POI) generally presents with irregular or missing periods and symptoms of low estrogen, like those Sandi was experiencing. Early menopause is also sometimes referred to as premature ovarian failure, a less accurate term since 5 to 10 percent of women can still recover their fertility and have a healthy pregnancy. As a doctor who helps women reverse post-birth-control syndrome, reset their hormones, and reclaim their fabulousness, I see how conditions like early menopause do more than just mess with your sex drive and make you a cranky mess.

Research shows the decrease in hormones that comes with early menopause also increases your risk of premature death, neurological diseases, psychosexual dysfunction, mood disorders, osteoporosis, ischemic heart disease, and infertility. For Sandi, those symptoms and potential risks came out of nowhere, and she wanted to do everything possible to alleviate them.

When is menopause actually supposed to start?

Menopause occurs when your menstrual cycle (and hence fertility) have been absent for at least a year. Your ovaries stop producing estrogen and progesterone, two of the main hormones you need for fertility. (FYI ladies: You can still get pregnant up to a year after your period has stopped.) Typically, the menopausal process—called perimenopause—kicks in during your mid- to late 40s. You stop making as much estrogen, and your periods occur less frequently. The average age for menopause is around 51. For some women, it can occur a bit later. For Sandi, it happened much earlier: She was 38, in fact, when she first visited her doctor with her concerns.

Researchers define early menopause as the end of ovarian function before age 45, and premature menopause affects about 1 percent of women under 40. The first red flag occurs when you start having changes in your menstrual cycles. Women typically report irregular, shorter, or longer periods as estrogen levels nose-dive.

Sandi hadn’t had her period in a year, she had nearly zero libido, her energy levels plummeted, and she either had sleepless nights or got really bad sleep. She was also putting on belly fat that she couldn’t lose, and low energy levels left her unmotivated to hit the gym regularly. Understandably concerned and frustrated, Sandi visited her doctor, who ordered some tests to determine whether her symptoms indicated early menopause or another condition. Among those tests included estradiol (to measure estrogen levels), follicle-stimulating hormone (to determine how well her ovaries functioned), and thyroid-stimulating hormone. From her results, Sandi’s doctor diagnosed her with primary ovarian insufficiency or early menopause.

What causes early menopause?

Sandi and her doctor felt baffled about what had triggered her early menopause. After all, she ate fairly healthfully, exercised regularly, and didn’t smoke or drink excessively. I explained that anything that compromises your estrogen production or damages your ovaries could result in early menopause. And that includes:

Radiation and chemotherapy (these can be reversible and your ovary may resume ovulation and menstruation after one year of amenorrhea)

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What are the symptoms of early menopause?

As Sandi emphatically verified during our initial consultation, symptoms of early menopause are vast and can be pretty brutal. They include hot flashes and night sweats, vaginal dryness, having to urinate often, incontinence, sexual dysfunction, and sleep disturbances, joint pain, and inability to concentrate. While these are similar to symptoms of menopause, early menopause can make them feel more intense.

Sandi had gone off the pill before I saw her, which had created additional birth control side effects. In my practice, I also see how birth control pills can mask many signs of early menopause. In Sandi’s case, they may have masked the symptoms of primary ovarian insufficiency for years.

Because the pill suppresses ovarian function, your ovaries aren’t making sufficient estrogen or progesterone. Instead, the pill provides synthetic estrogen and progestin, which means you still get your periods regularly as part of a withdrawal bleed, not to be mistaken for a "real" period. Because it can mask symptoms, the pill can make diagnosing menopause or (in Sandi’s case) early menopause difficult.

When Sandi visited me, I ran some additional tests. They revealed she had Hashimoto’s, the No. 1 cause of hypothyroid disease, where antibodies attack the cells in your thyroid gland and don’t make enough thyroid hormone. We also found that Sandi was negative for 21-hydroxylase antibodies, which causes autoimmune adrenal insufficiency. Approximately 3 percent of women with premature ovarian failure are found to have positive adrenal antibodies. Studies also show that autoimmune disorders contribute to 30 to 60 percent of early menopause, paving the way for other problems including type 2 diabetes, rheumatoid arthritis, and systemic lupus erythematosus.

What does early menopause say about your hormones?

To understand what was going on with Sandi, I had to stand back and connect some hormonal dots. Numerous hormones and systems play a role in early menopause (and menopause in general), and a key player is estrogen. The major source of estrogen is your ovaries and besides reproduction, estrogen plays a role in skin elasticity, supplying calcium to your bones, maintaining blood vessel flexibility, and managing lipid levels.

When you get your period, your hypothalamus sends a message to your pituitary gland, which triggers follicle growth and increases estrogen to stimulate the lining of your uterus to grow and thicken. Declining estrogen levels in early menopause means that process doesn’t happen. Instead, the number of ovarian follicles declines and your ovaries become less responsive to two other reproductive hormones, luteinizing hormone (LH) and follicle-stimulating hormone (FSH). As your ovaries age and release fewer hormones, they can’t effectively regulate estrogen, progesterone, and testosterone. That sends your hormones crashing and has detrimental repercussions.

Estrogen levels naturally get lower as you get older, but that doesn’t mean you need to settle with the sometimes-detrimental consequences. From a functional medicine perspective, menopause is more than just estrogen depletion or a cluster of miserable symptoms. Instead, we look at the whole system and all the potential hormonal imbalances.

Take your adrenals, for example: When they get out of whack, they can create or exacerbate menopausal symptoms like hot flashes and mood swings. Once the ovaries stop producing hormones, your adrenal glands provide dehydroepiandrosterone (DHEA), which your body converts to estrogen and testosterone. This is why you must be good to those adrenals. A high-sugar, starchy, processed-foods diet places stress on your adrenals and raises insulin, which can also trigger or exacerbate symptoms like hot flashes.

Because your ovaries make less estrogen and progesterone, your libido, mood, and exercise stamina can also nose-dive, all of which can leave you feeling more stressed out and anxious and create further hormone imbalances. That domino effect affects other hormones and systems. Thyroid issues and gut issues including leaky gut can all mess with your mood, considering that your gut manufactures about 95 percent of your feel-good neurotransmitter serotonin. Insufficient levels of thyroid hormone can also create depression, anxiety, and irritability and pave the way for early menopause.

I could go on (hormones are complex and can get messy), but you can see where I’m going: Once a few hormones get out of balance—in Sandi’s case, estrogen and insulin were the heavy hitters—others quickly follow.

Is there anything you can do about early menopause?

From a functional medicine perspective, when it comes to early menopause, we put together the pieces and find a protocol that works for the individual. That isn’t always easy and demands some detective work, but that’s the only way to restore hormonal balance and reduce miserable symptoms. Everyone is unique, and slapping on a one-size-fits-all label with menopause or early menopause dramatically oversimplifies the situation.

Sandi’s doctor suggested hormone replacement therapy (HRT) or estrogen replacement therapy (ERT), which can improve mood changes and other symptoms related to low estrogen levels during early menopause. Sandi wanted a more holistic approach to treat her symptoms, which is why she visited me. "There’s a lot you can do to eliminate symptoms of early menopause and reverse primary ovarian insufficiency," I told Sandi. In fact, upward of 10 percent of women are able to recover their fertility.

Research shows that eliminating processed foods and eating a lot more plant-based foods can reduce your risk of menopause-related side effects including depression and stress. That’s where we started: Cleaning up Sandi’s diet; removing hot-flash-inducing sugar, caffeine, alcohol, and other food sensitivities; and adding in lots of anti-inflammatory, antioxidant-rich whole foods.

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What are the most practical ways to address early menopause?

I’ve supported many woman in their journey to reclaim their body and break free from the symptoms holding them back, which is why I created a hormone reset program to help you kick your unwanted hormone symptoms and feel fabulous. During the initial and follow-up consultations, I used 12 strategies with Sandi to help reduce or eliminate many side effects of early menopause while we worked on the root cause. I also find these strategies work well with many patients who want to avoid early menopause.

1. Find your goal weight and maintain it.

Being underweight can trigger hormonal imbalances that reduce estrogen levels. Researchers find underweight women have over twice the risk of experiencing early menopause, whereas overweight and obese women have over 50 percent higher risk of experiencing late menopause. Sandi’s body had been cranking out cortisol, which was causing that extra weight to hang around her midsection. A whole foods diet along with natural ways to regulate blood sugar and weight resistance helped Sandi lose about 18 pounds over several months and reach her ideal weight.

2. Eat a ton of colorful foods.

Antioxidants protect against free radicals to prevent disease and slow down the aging process. Early menopause can age you quickly (Sandi said she felt she’d "aged about a decade" over the past year) by ramping up the free-radical machine. Stop that process with antioxidant-rich free-radical-busting foods including blackberries, strawberries, blueberries, artichokes, turmeric, and, Sandi’s favorite, dark chocolate. In addition, antioxidants like glutathione provide much-needed protection to your ovaries. Studies have shown that oxidative stress has a significant negative impact on ovarian function.

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3. Find an exercise plan that works for you—and do it.

Along with eating correctly, studies show consistent exercise can help prevent early menopause. For menopausal women, research shows women who exercise every day are 49 percent less likely to report bothersome hot flashes. (Women who subsequently decreased exercise during follow-up were more likely to experience those hot flashes.) Every patient has a different exercise strategy. For Sandi, that included weight resistance (she loved having toned arms when she helped photographers with shoots) and restorative yoga to balance stress levels.

4. Get sufficient nutrients.

While I use several supplements to address various symptoms of conditions like early menopause, I always start with foundational nutrients. For Sandi, that included a full-spectrum multivitamin-mineral fish oil to manage inflammation, B vitamins, and adaptogenic herbs including maca and rhodiola to provide overall hormone support. Research shows certain nutrients, including vitamins C, E, and the whole array of B vitamins, can relieve many menopausal symptoms. Remember, Sandi had been on the pill, which depletes nutrients like crazy and only compounds early menopausal symptoms. Other studies show foods high in vitamin D and calcium can lower your risk for early menopause. (Very few foods contain sufficient vitamin D, so I almost always supplement.) Sandi was also concerned about her risk for osteoporosis, so I used a nutrient formula that contains calcium, vitamin D, and other bone-support nutrients. And of course, she continued strength training to support her bones.

5. Manage stress.

Research shows chronic stress can elevate stress hormones like cortisol and ramp up the menopausal process. Conversely, early menopause can make your life incredibly stressful. Early menopause amplified Sandi’s already-stressed-out life as an editor. To help manage stress, she did yoga and paused every few hours while editing to focus on her breath. She also used calming nutrients including L-theanine, ashwagandha, and Rhodiola rosea to manage mood swings.

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6. Stop smoking.

Like most of my patients, Sandi didn’t smoke, but be aware: Among all the other nasty things it can do, smoking, studies show, can shorten your menstrual life. In fact, women who smoke have a 40 percent greater risk of developing early menopause than women who don’t.

7. Decrease alcohol and caffeine.

Studies show women who drink too much ramp up menopausal side effects, including hot flashes and night sweats. Sandi admitted to being a caffeine fiend, often downing black coffee many mornings as breakfast to fuel meeting magazine deadlines. I explained that third cup of dark roast can jack up your cortisol levels past their prime, making you anxious and jittery. She tapered to green tea and kept wine intake to a few glasses each week.

8. Eat estrogen-replenishing foods.

Phytoestrogen-rich foods like flaxseeds can greatly reduce menopausal symptoms. In one study, half the women ate a phytoestrogen-rich diet that included foods like flaxseeds; the other half didn’t. Symptoms like hot flashes and vaginal dryness decreased significantly in the phytoestrogen group. Sandi added freshly ground flaxseeds into her morning smoothie to get those phytoestrogens and other nutrients.

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9. Support vaginal dryness with these nutrients.

Because of vaginal dryness, Sandi often found sex painful. To relieve that problem, she used a 400-IU vitamin E suppository. She felt better but still suffered occasional sensitivity, so I also had her apply a topical DHEA for three months (you may need to use it longer) to support healthy vaginal tissue.

10. Go clean and green.

Harsh chemicals in anti-wrinkle creams can wreak havoc on your hormonal levels, and research shows phthalates and parabens in many beauty products can mess with your estrogen levels. Sandi had a whole array of beauty products, most of which were toxic. I helped her find cleaner alternatives. Ditto with environmental toxins in household products including kitchen cleaners, which studies show put women at greater risk of accelerating age-related hormonal processes.

11. Drink plenty of water.

Among its many benefits, filtered water helps detoxify your body to eliminate nasty toxins and hydrate your skin. Sandi kept a canteen in her bag filled with lime-infused filtered water, which she refilled twice a day so she could get about 75 ounces of water.

12. Keep your brain active.

As you get older, your brainpower gradually decreases. Estrogen is part of your brain’s signaling system that helps direct blood to more active parts of the brain. During menopause, some women report memory problems. I encouraged Sandi to constantly challenge herself, which she enjoyed doing anyway. For her, it meant getting out of her comfort zone by taking French-language lessons. She even signed up for salsa classes…where she met her current boyfriend.

Along with these strategies, Sandi visited a therapist who helped her work through the emotional changes early menopause can evoke. Together with my treatment, we created a protocol to help Sandi revive her libido, reach her healthy weight, and feel like her former confident, sexy self.

This didn’t happen overnight. For Sandi, it took about three months to eliminate her uncomfortable symptoms. The emotional repercussions of early menopause took longer to resolve with her therapist, but she felt much more confident after our last consultation. (Big bonus: After nearly two years, Sandi got her period back!)